{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CAROLYN   H RICE","gend":1,"add":"2598   RIVER RIDGE ROAD                                     ","city":"APPOMATTOX                    ","state":"VA","zip":"24522-7957","dob":"1963-07-28","age":"","mstatus":"","insh":10053687,"cliId":"","pno":4342197011,"cno":4342197011,"email":"","ename":"","eno":"","pphy":"DISPASQUALE-SEELIG, KATHLEEN                                ","ppno":"","pcpadd":"180 E BELT DR","pcpcity":"HENRICO                       ","pcpstate":"VA","pcpzip":232281204,"pcpcounty":"","pcpid":"P0144880","pcpname":"HENRICO AREA MENTAL HLTH AND DEVELOPMENT SERVICES","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"2598   RIVER RIDGE ROAD                                     ","madd2":"                                                            ","madd3":"","mcity":"APPOMATTOX                    ","mstate":"VA","mzip":"24522-7957","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G47.30","G47.52","Z71.9","R13.10","K29.50","K59.04","Z87.19","J44.9","G47.33","I50.9","J45.40","I25.9","Z71.89","Z71.3","R68.89","E78.9","I51.81","J96.90","J41.0","K57.30","K82.8","N20.1","N28.89","R10.13","D72.829","I25.2","K83.8","J20.9","F17.210","R05","Z79.82","J40","Z23","Z68.24","M25.512","K22.2","Z79.899","K29.70","L08.9","S81.811A","T14.8XXA","K59.00","E78.49","R06.09","Z72.0","F17.200","Z20.828","R06.00","I25.5","Z12.2","Z87.891","J98.4","I70.0","M79.671","M25.571","E78.00"],"date":["2019-01-08","2019-01-08","2019-01-08","2020-04-17","2020-02-18","2019-02-07","2021-10-26","2021-11-23","2021-11-23","2020-10-05","2019-05-02","2019-10-14","2020-09-25","2020-09-25","2019-05-14","2020-10-26","2021-11-23","2019-05-14","2019-05-14","2019-07-21","2019-07-23","2019-07-21","2019-07-21","2019-07-21","2019-07-21","2019-08-22","2019-07-23","2019-08-22","2020-02-18","2019-08-22","2020-02-18","2019-09-09","2020-04-13","2019-11-20","2020-01-03","2020-04-17","2020-02-18","2021-10-26","2020-04-13","2020-04-13","2020-04-13","2021-10-26","2020-04-21","2020-10-26","2021-08-13","2021-11-23","2020-12-23","2021-01-21","2021-08-13","2021-08-06","2021-08-06","2021-08-06","2021-08-06","2021-10-19","2021-10-05","2021-11-23"],"priorHcc":["","","","","","","",null,null,"","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","",null]}},{"a":[]}]},{"t":"Covid Screening","q":[{"a":[]}]},{"t":"Self-Assessment and Social History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Activities of Daily Living","q":[{"a":[]}]},{"t":"Medical History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Family History","q":[{"a":[]}]},{"t":"Preventive Care","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","00173068220","VENTOLIN","","18","Select","Select",""],["","29300022019","MONTELUKAST","10MG","30","Select","Select",""],["","59746021601","SPIRONOLACT","25MG","8","Select","Select",""],["","43547040211","FUROSEMIDE","40MG","30","Select","Select",""],["","55111015930","OMEPRAZOLE","40MG","30","Select","Select",""],["","57237010099","METOPROL","25MG","30","Select","Select",""],["","68645056854","ATORVASTATIN","40MG","30","Select","Select",""],["","00173088710","TRELEGY","ELLIPTA","60","Select","Select",""],["","00173072020","FLOVENT","220MCG","12","Select","Select",""],["","00186091612","PULMICORT","180MCG","1","Select","Select",""],["","45802086802","POLYETH","3350 NF","238","Select","Select",""],["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","00487950125","ALBUTEROL","0.08%","75","Select","Select",""],["","00310460012","BEVESPI","9-4.8MCG","10.7","Select","Select",""],["","45963043963","CONSTULOSE","10GM\/15","850","Select","Select",""],["","59310057922","PROAIR","","8.5","Select","Select",""],["","69097084507","CYCLOBENZAPR","5MG","30","Select","Select",""],["","49281042050","FLUZONE","2020-21","0.5","Select","Select",""],["","00173068220","VENTOLIN ","AER ","18","Select","Select",""],["","55111064530","OMEPRAZOLE ","CAP 40MG","90","Select","Select",""],["","29300022019","MONTELUKAST ","TAB 10MG","30","Select","Select",""],["","59746021601","SPIRONOLACT ","TAB 25MG","8","Select","Select",""],["","43547040211","FUROSEMIDE ","TAB 40MG","30","Select","Select",""],["","57237010099","METOPROL ","TAB 25MG","30","Select","Select",""],["","68645056854","ATORVASTATIN ","TAB 40MG","30","Select","Select",""],["","00173088710","TRELEGY ","AER ELLIPTA","60","Select","Select",""],["","00173072020","FLOVENT ","AER 220MCG","12","Select","Select",""],["","00186091612","PULMICORT ","INH 180MCG","1","Select","Select",""],["","45802086802","POLYETH ","POW 3350 NF","238","Select","Select",""],["","00143924920","AMOX\/K ","TAB 875-125","20","Select","Select",""],["","00487950125","ALBUTEROL ","NEB 0.00083","75","Select","Select",""],["","00310460012","BEVESPI ","AER 9-4.8MCG","10.7","Select","Select",""],["","45963043963","CONSTULOSE ","SOL 10GM\/15","850","Select","Select",""],["","59310057922","PROAIR ","AER ","8.5","Select","Select",""],["","69097084507","CYCLOBENZAPR ","TAB 5MG","30","Select","Select",""],["","49281042050","FLUZONE ","INJ 2020-21","0.5","Select","Select",""],["","49035030602","EQ ","POW ","238","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Review of Systems and Diagnoses","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""]]]},{"t":"Mini-Cog","q":[{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Active Problem Conditions","q":[{"a":[]}]},{"t":"Patient Summary","q":[{"a1":"","a2":"","a3":"","a4":"","a5":"","a6":"","a7":[],"a8":"","a9":"","a10":[],"a11":"","a12":""}]}]}